Alcohol and youth: time for effective action.

The problems associated with alcohol use were once largely considered to be primarily due to long-term heavy intake of ethanol. The major causes of death and hospitalization attributed to alcohol use were thought to be chronic diseases such as cirrhosis and alcohol dependence. Until recently, this view was largely supported by available research. The health benefits of alcohol consumption were not well established, and prevailing estimates of alcohol-related mortality indicated chronic disease accounted for most alcohol-related deaths. Based on results of a 1984 Health Canada expert committee regarding the attribution of alcohol to major causes of death, it was estimated that 80% of alcohol-attributable deaths were due to chronic disease and alcohol dependence. Youthful drinking was viewed with benign neglect – although there were concerns that consumption rates established in youth influence lifelong drinking patterns, youthful drinking in itself was not seen as a major component of alcohol-attributable mortality. We now know differently. More recent estimates indicate that acute causes contribute a great deal more to overall levels of alcohol-related mortality than previously thought. Unlike earlier results, these estimates are based on specific disease categories controlling for age and gender. They show that accidents, suicide and other acute causes actually account for approximately one half of the deaths caused by alcohol misuse. Furthermore, because such deaths often involve young persons, acute causes account for two thirds of years of potential life lost due to alcohol misuse. Mitic and Greschner’s timely analysis of the role of alcohol in the deaths of British Columbia youth and children corroborate these findings. One could raise questions regarding their exact findings – only a subset of youthful fatalities are available for analysis and, as the authors are well aware, the attribution of causality based solely on whether or not drinking had taken place, is subject to criticism. But combined with evidence from other sources, the primary conclusion of their analysis is undeniable: alcohol plays a major role in the premature death of our children and youth. Given the significance of alcohol to youthful mortality, the key issue is what should be done to enhance the effectiveness of prevention policy and programming. Not long ago, when the primary problems associated with alcohol were chronic conditions stemming from long-term drinking, the answer to this question would have focused on controls over alcohol availability and preventive programming emphasizing the message that drinking less is better. The use of tax policy and availability controls to reduce alcohol problems has certain advantages. Such population-based measures are relatively easy to implement. There is reasonably good evidence that they can reduce levels of drinking and alcohol problems. Tax measures and availability controls also produce substantial revenue and signal official concern about alcohol problems. However, control measures also have distinct disadvantages. They are not well targeted and fail to address situational determinants of drinking problems. As successful availability controls tend to reduce drinking at all levels of consumption, they may inadvertently reduce cardiovascular benefits from low-level consumption. Recent studies in Australia, New Zealand, Canada and Finland have all found that low-level alcohol use prevents a significant number of deaths. Although alcohol consumption generally only adds a few years of life among some older persons, the fact that there are significant benefits from drinking has eroded political support for availability controls. Perhaps most importantly, Mitic and Greschner’s findings indicate that control measures to date have not been effective with regard to youthful drinking problems. Fortunately, a new type of preventive strategy has emerged in the recent past. These measures have been termed “harm reduction” because they attempt to decrease the risk and severity of adverse consequences of drinking without necessarily decreasing the level of consumption. Rather than “drinking less is better,” the key prevention message is “avoid problems associated with drinking.” Examples of harm reduction measures include server intervention programs; modifications to the physical environments where drinking takes place (e.g., by padding furniture); expanding hours of retail outlets to reduce methanol poisonings among dependent users; impaired driving countermeasures which aim at separating drinking from driving; and preventive education on ways to reduce risks or deal with problems in situations where excess drinking occurs. Such harm reduction strategies should be viewed as complementary rather than as substitutes for measures aimed at reducing alcohol consumption. There are still good reasons to favour reasonable controls over alcohol availability. The maintenance of alcohol taxes at levels indexed to inflation can be justified in terms of recovering the costs of alcohol to governments and society, and controls are clearly required for underage drinking and excessive promotion of alcohol. What is required is to find the appropriate balance between control measures aimed at restricting drinking levels and more targeted harm reduction strategies aimed at preventing problems when drinking takes place. Indeed, Mitic and Greschner suggest a combination of harm reduction and control measures when they propose lowering the BAC limits for drivers transporting children, increasing the price of alcohol, and increasing public awareness as measures to reduce mortality from alcohol use among youth. Specific areas where Senior Associate, Canadian Centre on Substance Abuse; Professor of Public Health Sciences, University of Toronto; Honorary Professor, Curtin University, Perth, Australia (6 Mervyn Avenue, Toronto, ON M9B 1M6). Acknowledgements: The author gratefully acknowledges the comments of Robert Solomon, Lisa Powell and Richard Garlick.